【作者】 陈雷；

【导师】 李康华；

【作者基本信息】 中南大学 ， 外科学， 2007， 博士

【摘要】 颈椎间盘退变是颈椎退行性疾病发生与发展的核心病理基础，椎间盘退变常伴随钩椎关节和关节突关节退变，并影响到椎动脉，因此颈椎横突孔及邻近关节骨性结构的形态学研究具有重要的临床意义。颈椎前路椎间盘切除植骨融合内固定术已成为治疗颈椎退行性疾病的“金标准”，而目前研究发现该术式术后由于改变了相邻节段椎间盘压力、节段间运动力学和关节突关节应力，从而导致邻近节段退变。颈椎人工椎间盘植入目的是替代病变的椎间盘，保留节段运动和减少相邻节段继发性退变。颈椎双节段人工椎间盘置换已经初步应用于临床，而关于双节段颈椎人工椎间盘置换后颈椎生物力学研究报道较少，由于颈椎关节突关节具有十分重要的生物力学作用，同时关节突关节退变速度和程度也是判定颈椎病术后疗效的重要指标之一，因此，对比双节段颈椎人工椎间盘置换、颈椎椎间盘摘除、椎间融合内固定和对下位节段关节突关节影响的实验研究和临床观察，具有重要的生物力学和临床意义。本课题从以下三个方面进行了研究：（1）测量颈椎横突孔及其邻近关节骨性结构的关系。（2）测量新鲜尸体标本C_4／5、C_5／6椎间盘摘除、椎间融合内固定和人工椎间盘置换模型在不同载荷下对C_5／6、C_6／7关节突关节内压力的影响。（3）观察C_4／5、C_5／6人工颈椎间盘置换和颈椎椎间融合术的临床疗效和对邻近下位关节突关节的影响。第一章颈椎横突孔的解剖测量目的：测量颈椎横突孔横径、矢状径及横突孔与周围关节的关系，为颈椎间盘退变继发骨质增生引起的椎动脉型颈椎病临床诊断和手术治疗提供解剖学依据。方法：对11具新鲜颈椎标本进行CT扫描和标本测量1．横突孔的横径、矢状径；2．横突孔至钩突外缘距离与相对于双侧钩突外缘距离的相对距离；3．横突孔到关节突关节前缘距离和相对于关节突前后径相对距离。结果：1．对C₁～C₇颈椎横突孔横径、矢状径左右侧进行比较没有显著性差异（P＞0.05），C₁～C₆两两比较横突孔的横径和矢状径没有显著性差异（P＞0.05），C₇横突孔孔径最小，比较有显著性差异（P＜0.05）。2．对C₃～C₇横突孔至钩突外缘距离进行两两比较，没有显著性差异（P＞0.05）；C₄、C₅、C₆横突孔至钩突外缘相对距离进行两两比较，没有显著性差异（P＞0.05），C₄、C₅、C₆横突孔至钩突外缘相对距离比C₃、C₇小，有显著性差异（P＜0.05）。3．C₃～C₇横突孔到关节突关节前缘距离之间两两比较，没有显著性差异（P＞0.05）；C₅、C₆横突孔到关节突关节前缘相对距离比C₃、C₄、C₇最大，有显著性差异（P＜0.05）。CT测量值和实测值之间比较没有显著性差异（P＞0.05）。结论：1．横突孔孔径C₁～C₇左右侧横突孔孔径没有差异，C₇横突孔最小。2．C₃～C₇左右侧横突孔至钩突外缘距离没有差异，C₄、C₅、C₆横突孔至钩突外缘相对距离近，距离椎动脉相对近。3．C₃～C₇左右侧横突孔至关节突关节前缘距离没有差异，C₅、C₆横突孔到关节突关节前缘相对距离最大。第二章C_4／5、C_5／6人工椎间盘置换对C_5／6、C_6／7关节突关节压力影响的实验研究目的探讨双节段颈椎椎间盘摘除、人工椎间盘置换和前路椎间融合内固定对下位节段关节突关节内压力的影响，为双节段人工颈椎间盘置换的临床运用提供生物力学依据。方法取11具新鲜完整的成人下颈段标本，按实验先后分别制成C_4／5、C_5／6椎间盘完整、椎间盘摘除、椎间盘置换、椎间融合四个模型组，在标本上施加轴向、侧弯、前屈和后伸分级载荷，将特制圆片状微型阻电式压力传感器置入C_5／6、C_6／7关节突关节内，测量合组各分级载荷下C_5／6、C_6／7关节突关节内的压力，比较各组的压力大小，用SPSS13.0统计软件包进行统计学分析。结果1．在轴向、侧弯、前屈和后伸加载下，下位节段关节突关节内的压力随着施加载荷的增大而增大。2．C_4／5、C_5／6双节段人工椎间盘置换组与椎间盘完整组相比下位置换节段和邻近下位节段关节突关节内的压力变化相近，无显著性差异（P＞0.05）。3．C_4／5、C_5／6双节段椎间盘摘除组与椎间盘完整组、人工椎间盘置换组相比，摘除下位节段和邻近下位节段关节突关节内的压力在轴向、同侧弯、对侧弯、后伸载荷压力增加（P＜0.05），在前屈载荷时降低，有显著性差异（P＜0.05）。4．C_4／5、C_5／6椎间融合组与人工椎间盘置换组、椎间盘完整组相比邻近下位节段关节突关节内的压力高，有显著性差异（P＜0.05）。结论1．颈椎双节段人工椎间盘置换后置换下位节段和邻近下位节段关节突关节内压力与完整标本相近，提示颈椎双节段人工椎间盘置换能够重建颈椎生物力学性能。2．颈椎双节段椎间盘摘除后可引起摘除下位节段和邻近下位节段关节突关节压力发生不同程度的改变。3．颈椎双节段椎间盘摘除融合内固定后邻近下位关节突关节压力增加，可能是多节段颈椎融合术后邻近节段发生退变或退变加速的原因之一。第三章双节段人工颈椎间盘置换与融合术的临床疗效观察目的观察颈椎双节段人工椎间盘置换和前路融合内固定术的临床疗效，探讨不同术式对邻近下位关节突关节退变的影响。方法收集C_4／5、C_5／6双节段颈椎退行性病变而接受手术病例35例，按照手术方式及随访时间分为三组：（1）颈椎双节段人工椎间盘置换组5例，随访12个月～22个月；（2）前路双节段椎间盘切除植骨融合内固定短期随访组（融合组一）15例，随访12个月～30个月；（3）前路双节段椎间盘切除植骨融合内固定中长期随访组（融合组二）15例，随访5年。对术前和术后6月、1年、2年、5年进行JOA评分、Odom评级，X线观察邻近下位节段活动度，X片和CT扫描分析术后手术邻近下位节段的关节突关节的退变程度。运用SPSS13.0统计软件对观察结果进行比较分析。结果1．JOA评分、Odom评级：三组术后各随访时段的较术前均有提高（P＜0.05），术后6月、1年颈椎双节段人工椎间盘置换组与融合组一比较无显著性差异（P＞0.05）；融合组二术后1年与术后6月比较无显著性差异（P＞0.05），融合组二术后5年与1年、2年比较降低（P＜0.05）；2．邻近下位节段活动度：术后6月、12月双节段人工椎间盘置换组与融合组一比较无显著性差异（P＞0.05），融合组二术后5年与1年、2年比较，邻近下位节段活动度增加（P＜0.05）；3．术后6月、12月双节段人工椎间盘置换组与融合组一的退变程度比较均无统计学差异（P＞0.05），融合组二术后5年与1年、2年比较，关节突关节的退变率增加（P＜0.05）。结论1．颈椎双节段人工椎间盘置术和前路植骨融合术治疗双节段颈椎间盘疾患的近期手术疗效均良好，对邻近下位节段关节突关节退变影响不明显。2．前路植骨融合内固定术后中远期疗效降低，邻近下位节段关节突关节出现退变。3．双节段颈椎人工椎间盘置术的中远期疗效有待进一步观察。更多还原

【Abstract】 Cervical disc degeneration is the basic pathology of degenerativecervical spondylosis. Cervical disc degeneration is always followed bydegeneration of uncovertebral joint and zygapophyseal joint, which oftenaffect vertebal artery. Thus it’s necessary to study anatomical property fortransverse foramen and strctures closed to it.Anterior cervical decompression and fusion（ACDF） has become agolden standard management for cervical degenerative disease. HoweverACDF is regarded correlated to the changes of adjacent kinetics andstress distribution of intrvertebral disc and zygapophyseal joint,adjacent cervical segment degeneration happens thereafter. As analternative management to degenerated cervical disc, cervical artificialdisc replacement preserves motion at the instrumented levels andpotentially decrease degeneration rate of adjacent segment. Two-levelcervical artifical disc repacement （ADR） has been used primarily inclinic, However there is few report about biomechanics of two levelcervical artificial disc replacement, nor is experimental or clinical studyof comparisons of the effects of two level ADR, Anterior cervicaldiscectomy（ACD） and ACDF to inferior adjacent zygapophyseal joint,which is important in biomechanics and usually used to evaluate adjacentsegment degeneration degree post-operatively.The current study was undertaken to investigate in the followingthree parts: （1）measuring cervical transverse foramen and its relation toadjacent sturctures.（2）exploring the effect to stress ditribution of C_5/6, C_6/7zygapophyseal joint in cadaveric cervical specimens under variousloadings following ACD, ACDF and ADR at C_4/5, C_5/6 level. （3）observingthe clinical effects of ADR and ACDF at C_4/5, C_5/6 level and the relatedeffects at the adjacent zygapophyseal joint.CHAPTER ONE: Anatomical Measurement of Transverse ForamenObjectives: To measure transverse diameter and saggital diameterof transverse foramen and its relation to adjacent structures so as to provide reference of anatomy and morphology for the basis of clinicdiagonosis, surgical management for cervical spondylosis.Methods: 11 fresh cervical specimens of adult cadavers were usedthrough the CT scan and practical measurement to measure transversediameter and saggital diameter of the transverse foramen; positive andrelative distance between transverse foramen and uncovertebral joint;positive and relative distance between transverse foramen andzygapophyseal joint. One-Way ANOVA and Paired-Samples T Testwere used to detect significant changes of the difference in eachsegment.（α=0.05）Results: （1） there was no significant difference of the transversediameter and sagittal diameter between left and right transverse foramenfrom C₁ to C₇（P＞0.05）. The diameter of C₇ transverse foramen issmallest（P＜0.05）. （2）there is no significant difference of positive distancebetween transverse foramen and uncovertebral joint from C₃ to C₇（P＞0.05）, the relative distance between transverse foramen anduncovertebral joint of C₃, C₇ is larger than that of C₄ to C₆（P＜0.05）;（3）there is no significant difference of positive distance betweentransverse foramen and zygapophyseal joint from C₃ to C₇（P＞0.05）, therelative distance between transverse foramen and zygapophyseal joint ofC₅, C₆ is larger than that of C₃, C₄, C₇（P＜0.05）. There was no significantdifference between the values of measurement through CT scan andpractical measurement（P＞0.05）.Conclusions: （1） there was no difference of the transverse diameterand sagittal diameter between left and right transverse foramen from C₁to C₇. the diameter of C₇ transverse foramen is smallest. （2） the relativedistance between transverse foramen and uncovertebral joint of C₄ to C₆is small, transverse foramens from C₄ to C₆ are close to vertebral artery.（3）the relative distance between transverse foramen and zygapophyseal jointof C₅ and C₆ is large. transverse foramen from C₄ to C₆ are relatively farfrom zygapophyseal joint. Chapter two: The Biomechanical Study of the Effect of C_4/5 and C_5/6two Level Artificial Disc Replacement to Stress Distribution inZygapophyseal Joint of C_5/6 and C_6/7Objectives: To study the impact caused by two level ACD, ADR andACDF on cervical adjacent zygapophyseal joint stress distribution, thusto provide reference for clinical application of two level ADR.Methods: Eleven healthy adult fresh-frozen multi-segmentalcervical spine segments were utilized in this study and biomechanicallyevaluated under the following C_4/5, C_5/6 cervical disc conditions: （1）intactspine（intact group）; （2）discectomy（ACD group）; （3）the Bryan Discprosthesis implantation（ACDR group）; （4）the intervertebral fusion（ACDFgroup）. The testing was performed by using INSTRON computedmechanics test system （made in England）. The load（25N～150N） of axial,flexion, extension, and lateral bending were applied on each group. Thestress changes of the caudad (C_5/6, C_6/7) zygapophyseal joint was tested bymodified cyclo-shaped miniature transducer. The data was analyzed bySPSS for windows 13.0, the statistic significance was set atα=0.05.Results: （1）Under axial, flexion, extension and lateral bendingloading, stress of the caudad (C_5/6, C_6/7) zygapophyseal joint increase asthe load increase. （2） Under axial, flexion, extension and lateral bendingloading, the stress of the caudad (C_5/6, C_6/7) zygapophyseal joint showedno difference between the intact group and ACDR group（P＞0.05）. （3）Under axial, extension and lateral bending loading, two level disectomyindicated a significant increase in the stress of the caudad (C_5/6, C_6/7)zygapophyseal joint compared to intact group and ACDRgroup（P＜0.05）, whereas under flexion loading there was a decrease ofStress （P＜0.05）. （4） Under axial, flexion, extension and lateral bendingloading, the ACDF group resulted in significant increase of the stress ofthe caudad (C_5/6, C_6/7) zygapophyseal joint compared to intact group andACDR group（P＜0.05）.Conclusions: 1.Two level artificial cervical disc replacement canmaintain stress in the caudad (C_5/6, C_6/7) zygapophyseal joint, thusreconstruct biomecanical property of cervical spine. 2. Two level cervicaldiscectomy can bring a certain degree of change in stress of the caudad (C_5/6, C_6/7) zygapophyseal joint. 3. Two level cervical discectorny andfusion can increase stress in the caudad (C_5/6, C_6/7) zygapophyseal joint,which may be one of the causes for adjacent cervical spondylosispostoperatively.Chapter there: The Clinical Observation of The ClinicalOutcomes After Two Level Artificial Disc Replacement andAnterior Cervical Discectomy and FusionObjectives:To observe the clinical outcome of the patients whoaccepted two level Bryan artificial disc replacement and patients withcervical discectomy and fusion, and analysis the effect on the caudadzygapophyseal joint.Methods: 35 patients with cervical C_5/6 and C_5/6 two level cervicaldisc degenerative spondylosis treated with two different operations werefollowed. They were divided into three groups according to the means ofoperation and time as followed: the group of artificial discreplacement（ACDR group）, 5 cases were treated with two level artificialdisc replacement with a follow-up study of 12-22months; the group ofshort term of anterior cervical discectomy and fusion（ACDF group1）, 15cases received operation with a follow-up study of 12-30 months; thegroup of medium and long term of anterior cervical discectomy andfusion（ACDF group2）, 15 cases received operation with a follow-upstudy of 5-8 years. The score of JOA, the scale of Odom, the range ofmotion（ROM） shown by X-ray film of adjacent segment and the, degreeof degeneration revealed by X-ray and CT scan of adjacent caudadzygapophyseal joint in 6, 12 months and 2-year, 5-year were analyzedpre-operatively and post-operatively. The data was analyzed by SPSS forwindows 13.0, Paired-samples T Test was used to detect the differenceamong the different groups, the statistic significance was set atα=0.05.Results: （1） The score of JOA and the rank of Odom:There aresignificant difference between pre-operation and different period of post- operation（P＜0.05）. There are no difference in score of JOA, rank ofOdom, between the group of artificial disc replacement and the ACDFgroup1 of intervertebral fusion in 6 months and 1 year follo-uppostoperatively （P＞0.05）. the score of JOA and rank of Odom in theACDF group2 decreased in 5 years compaered with 1 and 2 yearpost-operatively （P＜0.05）; （2） The range of motion of adjacent caudadsegment: There are not difference in between the group of artificial discreplacement and the ACDF group1 of intervertebral fusion in 6 monthsand 1 year follo-up postoperatively （P＞0.05）; The range of motion ofadjacent caudad segment in the ACDF group2 increased in 5 yearscompaered with 1 and 2 year post-operatively （P＜0.05）; （3） The degree ofdegeneration of adjacent caudad zygapophyseal joint: There are notdifference in between the group of artificial disc replacement and theACDF group1 of intervertebral fusion in 6 months and 1 year follow-uppostoperatively （P＞0.05）; The degree of degeneration of adjacent caudadzygapophyseal joint in the ACDF group2 increased in 5 years compaeredwith 1 and 2 year post-operatively （P＜0.05）.Conclusions: （1）The short term outcomes of two level artificial discreplacement or anterior cervial discectomy and fusion are satifactory, noobvious degenerative effects showed in adjacent caudad zygapophysealjoint. （2）The midium and long term outcomes of two level cervialdiscectomy and fusion decrease and degeneration occurs in adjacentcaudad zygapophyseal joint. （3）Further observation still needed to studythe medium and long term clinical outcomes of two level artificial discreplacement.更多还原